Low Cancer Risk in Barrett Esophagus With Irregular Z Line

David A. Johnson, MD


April 03, 2017

Low Risk of High-Grade Dysplasia or Esophageal Adenocarcinoma Among Patients With Barrett's Esophagus Less Than 1 cm (Irregular Z Line) Within 5 Years of Index Endoscopy

Thota PN, Vennalaganti P, Vennelaganti S, et al
Gastroenterology. 2016 Dec 15. [Epub ahead of print]

Study Summary

A recent study[1,2] demonstrated that the crude annual risk for the development of esophageal adenocarcinoma (EAC) was 0.25%. This was notably lower than prior reports from tertiary referral centers, but consistent with other European reports and a US study of veterans.[3] Although there is consensus that the risk for EAC increases with the length of Barrett esophagus (BE), the specific risks for progression to high-grade dysplasia or EAC are less clear in short-segment BE (SSBE)—defined as < 1 cm intestinal metaplasia in the distal esophagus, and also known as an irregular Z line.

In this prospective, multicenter outcome study, a large and well-defined cohort of patients with BE from several tertiary care referral centers in the United States and Europe were evaluated. It included 1791 patients with nondysplastic BE, both at the index endoscopy and after 1 year or more of follow-up.

After a median follow up of 4.8 years, there were 71 instances of progression to high-grade dysplasia or EAC for patients with BE ≥ 1 cm (n=1624) compared with no such cases in those in the cohort with SSBE/irregular Z line (n=167). There were no significant demographic differences between these two groups.


The most recent national guideline[4] from the American College of Gastroenterology states to not biopsy for SSBE when there is a normal Z line or when there is < 1 cm of columnar-appearing mucosal variability at the esophagogastric junction. Recognizably, intestinal metaplasia of the cardia is evident in up to 20% of patients, whereas the natural history of this at the esophagogastric junction is not associated with EAC.

The findings of this study strongly support the guideline recommendations from the American College of Gastroenterology that an irregular Z line, in the absence of specific mucosal irregularity (eg, nodule, ulcer, crypt irregularity), is not to be biopsied.


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